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Nursing home plagued by deficiences prior to resident's mysterious death

A Thunderbolt nursing home where an 80-year-old man was found dead last month had been fined and threatened with the loss of insurance coverage after repeated problems during a two-year inspection period, records indicate.

Tara at Thunderbolt Nursing and Rehabilitation Center was cited for 24 deficiencies during inspections that took place from Dec. 1, 2006, through Feb. 29, 2008.

The state average is seven deficiencies during such a period.

Most of the findings occurred during the last routine inspection on Sept. 19, 2007, when 16 deficiencies were discovered. Additional deficiencies were found after complaints triggered new inspections.

A second nursing home owned by Tara's parent company, Ocean- side Nursing and Rehabilitation Center on Tybee Island, had 18 deficiencies.

After the April incident, an autopsy indicated Walter Heath had been dead for two to three days before his body was discovered two days after his 80th birthday in a closet of Tara at Thunderbolt.

Heath had checked himself into Tara in February but wasn't restricted to the grounds of the facility.

No one will be charged with a crime, according to police. Heath did not die at the hands of anyone else, police said, and the nursing home was not found to be criminally negligent.

Hypothermia and exposure caused his heart to fail, according to autopsy results.

How he got into the closet remains a mystery.

The institution had faced scrutiny on numerous occasions before Heath disappeared on April 16.

Records show the federal Department of Health and Human Services found that the nursing home did not meet federal long-term care requirements five times since February 2007.

Fines of $200 a day were imposed on Feb. 14 after a January inspection that was prompted by a complaint. An initial follow-up visit the next month found things had not improved.

The state threatened to deny further Medicare and Medicaid payments if the deficiencies were not corrected by April 11. If the nursing home didn't achieve compliance by July 11, its Medicare and Medicaid provider agreements would have been terminated.

On Feb. 27, the nursing home was found to be in compliance, and the daily fine was rescinded. But the state is investigating again in the wake of Heath's death.

Savannah Beach had six deficiencies, while Oceanside had 18 - and 17 of those were discovered during an inspection Feb. 28.

Triad President and CEO Adam Ashpes said the number of deficiencies is not the issue. Nursing homes are going to have deficiencies as part of the review process, he said.

"If all of the facilities were constantly in compliance, then there wouldn't be surveys," Ashpes said.

Particular deficiencies and how the facility responds is his concern, he said.

Problems found

During five inspections since February 2007, the state found residents at Tara who were improperly assisted, inadequately supervised and facing "the potential for more than minimal harm."

The deficiencies included untreated bed sores and unchanged diapers.

A resident with Parkinson's disease reportedly lost 12 pounds in one month after employees failed to help the resident eat.

One resident who was dependent on staff to get around fell 31 times in 180 days because of inadequate assistance.

Employees did not ensure that a prescribed pain patch was consistently given to a hospice patient with chronic pain.

A certified nursing assistant failed to clean an incontinent patient in such a way that she would not suffer a urinary tract infection.

Residents reported waits of 45 minutes or longer to get helped to the bathroom.

One patient said some residents would call out "all night long" when their call light was not answered.

A family member said that when the nursing station was asked for help, the staff would often respond, "That's not my patient" or "that's not my job."

Also found were improperly cooked food, broken furniture and cold shower rooms because a water heater was disabled.

Triad has responded by replacing employees, including Tara's director of nursing, and submitting a state correction plan. The deficiencies are constantly being reviewed and corrected, Ashpes said.

"We take this seriously," he said. "It's a process of assessment and moving the systems forward. People caring for people is the hardest job out there. That being said, it can always be done better."

One family's concerns

The issues were not corrected fast enough for Dottie Hunter, who pulled her 84-year-old mother out of Tara in April.

"They always said it would be taken care of," Hunter said. "I got tired of those words."

She said she and her brother had to constantly change her mother's diaper and bed linens after the nursing home staff failed to do so.

Her mother would go days, sometimes weeks, without a bath, she said, and had to be sent to the hospital three times while at Tara.

First, Hunter said, her mother developed a urinary tract infection and pneumonia. Gallstones in her pancreas prompted the second visit. While the stones were being removed, a blood clot was discovered.

She was sent back to the nursing home to be treated, Hunter said, but the woman soon developed a knot on her side where the nursing home staff administered the blood thinner.

The knot grew from the size of a lemon to that of a basketball in three days, Hunter said, and her mother developed bruises from her neck to her knees.

When the nursing home's doctor visited the next day, he refused to check on her, Hunter said.

"He said he didn't think she needed to be seen," Hunter said.

Hunter's brother had his mother sent to the emergency room.

"She went to the hospital, and we didn't let her go back," Hunter said.

Now, Hunter said, her mother is living at a nursing home in Springfield, and her health has improved significantly.

"She was so depressed in the other one," Hunter said. "She seems to have a new lease on life, and it's only been a month.

"I just feel bad for the ones that are still there. Most people don't have family to come visit every day."

Questions linger

Heath's family, as well as investigators, still have questions regarding his death, said Capt. James Pierce of the Thunderbolt Police Department.

How long he had been in the closet before being found is one of the biggest mysteries.

Two sightings were reported after Heath vanished, but they have been discounted. When questioned, the witnesses said they saw someone who looked like Heath, which was not unusual.

The investigation indicated Heath had been confined to a wheelchair until a few days prior to his disappearance, Pierce said. He then began to walk for short periods.

Heath's wheelchair was found in the dining area near the closet where his body was found.

The employee who discovered Heath's body said he had to unlock the door before going in. The police officer used the key when he arrived.

The closet was used to store holiday decorations, and it was checked about once a month, Pierce said.

Employees told police they searched the closet the night Heath disappeared. The next time it was opened, they said, was when Heath's body was discovered.

What caused his death did not discount the possibility that Heath had been in the closet the whole time, Pierce said. When discovered, Heath was naked from the waist down and wet from urine.

The tile floor would be cold for anybody, especially an elderly person.

"There are some things we just don't know," Pierce said, "and probably never will."

Nursing home reports

The state average is seven health deficiencies.

Azalealand Nursing Home

Last standard survey: Jan. 4, 2007

Residents: 90

Health deficiencies: 5

Candler Hospital Subacute Unit

Last standard survey: April 26, 2007

Residents: 10

Health deficiencies: 1

Heritage Healthcare of Savannah

Last standard survey date: Oct. 18, 2007

Residents: 91

Health deficiencies: 14

Oaks Health Center at the Marshes of Skidaway Island

Last standard survey: May 23, 2007

Residents: 7

Health deficiencies: 14

Oceanside Nursing and Rehabilitation Center

Last standard survey: Feb. 28, 2008

Residents: 74

Health deficiencies: 18

The Place at Pooler

Last standard survey: Sept. 26, 2007

Residents: 76

Health deficiencies: 22

Riverview Health and Rehabilitation Center

Last standard survey: Jan. 9, 2008

Residents: 202

Health deficiencies: 6

Savannah Beach Nursing and Rehabilitation Center

Last standard survey: Jan. 24, 2007

Residents: 48

Health deficiencies: 6

Savannah Rehabilitation and Nursing Center

Last standard survey: Oct. 25, 2007

Residents: 110

Health deficiencies: 8

Savannah Specialty Care Center

Last standard survey: June 13, 2007

Residents: 90

Health deficiencies: 0

Savannah Square Health Center

Last standard survey: Jan. 12, 2008

Residents: 38

Health deficiencies: 15

St. Joseph's Hospital Transitional Care Unit

Last standard survey: Jan. 24, 2007

Residents: 6

Health deficiencies: 2

Tara at Thunderbolt Nursing and Rehabilitation Center

Last standard survey: Sept. 19, 2007

Residents: 133

Health deficiencies: 24

Westview Nursing and Rehabilitation Center

Last standard survey: Sept. 29, 2007

Residents: 83

Health deficiencies: 3

Source: U.S. Department of Health and Human Services

Tara at Thunderbolt inspection timeline

(November 2006-March 2008)

Nov. 29, 2006: In compliance.

Dec. 19, 2006: In compliance.

Jan. 22, 2007: No deficiencies cited.

Feb. 9, 2007: Not in compliance. Deficiencies: (1) Failure to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. (2) Failure to make sure that all needed doctor visits are made personally by a doctor, as required.

Feb. 27, 2007: Complaint inspection finds no deficiencies.

April 13, 2007: In compliance.

June 6, 2007: Complaint survey finds no deficiencies.

Aug. 9, 2007: Complaint survey finds not in compliance. Deficiences: (1) Failure to give each resident care and services to get or keep the highest quality of life possible. (2) Failure to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Sept. 4, 2007: Complaint survey finds no deficiencies.

Oct. 3, 2007: Complaint survey finds no deficiencies.

Sept. 19, 2007: Not in compliance. Deficiencies: (1) Failure to give each resident care and services to get or keep the highest quality of life possible. (2) Failure to give professional services that follow each resident's written care plan. (3) Failure to give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. (4) Failure to make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. (5) Failure to make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. (6) Failure to make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. (7) Failure to store, cook and give out food in a safe and clean way. (8) Failure to make sure that residents who take drugs are not given too many doses or for too long, to make sure that the use of drugs is carefully watched; to stop or change drugs that cause unwanted effects. (9) Failure to have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. (10) Failure to get rid of garbage properly. (11) Failure to have a program to keep infection from spreading. (12) Failure to keep temperature levels comfortable and safe. (13) Failure to make sure that a working call system is available in each resident's room or bathroom and bathing area. (14) Failure to provide needed housekeeping and maintenance. (15) Failure to put firmly secured handrails on each side of hallways. (16) Failure to keep accurate and appropriate medical records.

Oct. 23, 2007: Complaint survey finds no deficiencies.

Oct. 31, 2007: Revisit finds in compliance.

Nov. 14, 2007: Revisit finds in compliance.

Jan. 11: Complaint survey finds not in compliance. Deficiencies: (1) Failure to immediately tell the resident, doctor and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. (2) Failure to make sure that the nursing home area is free of dangers that cause accidents.

Feb. 14, Complaint revisit finds not in compliance. A $200 a day fine was imposed but was lifted on Feb. 27 when the home was found in compliance.